MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION JEFFERSON CITY, MISSOURI APPLICATION FOR SELF-INSURANCE TRUST (To be executed and sworn to in triplicate) ALL INFORMATION CALLED FOR ON APPLICATION MUST BE IN TYPEWRITTEN FORM The undersigned Trust Fund hereby makes application to carry its own liability without insurance as provided in the Missouri Workers’ Compensation Law. In connection with such application it makes the following declaration for the purpose of enabling the Division of Workers’ Compensation to determine whether it possesses sufficient financial ability to render certain the payment of compensation which its employees and their dependents may be entitled to under the Missouri Workers’ Compensation Law. Applicant hereby agrees that if this application be approved, such approval shall be subject to its furnishing such security as may be required by the Division of Workers’ Compensation. Applicant further agrees to abide by all of the provisions of the Missouri Workers’ Compensation Law and by the rules governing self-insurers under said law. _________________________________________________________________________________________________ (Effective Date) Official Name of Trust Fund 1. Address of Principal Office ________________________________________________________________________ (Number) 2. Trustees (Street) Name (City) (State) (Zip Code) Business Address ____________________________________________ _____________________________________________ ____________________________________________ _____________________________________________ ____________________________________________ _____________________________________________ ____________________________________________ _____________________________________________ ____________________________________________ _____________________________________________ ____________________________________________ _____________________________________________ 3. Administrator ___________________________________________________________________________________ (Name) (Address) (Telephone Number) 4. Claims Program _________________________________________________________________________________ (Name of Service Company) (Address) (Telephone Number) 5. Safety Program __________________________________________________________________________________ (Name of Person Responsible) (Telephone Number) WC-81A (8-99) AI 2000 (C) American LegalNet, Inc. 6. Total Number of Employer Members ______________ (Attach List of Members) Total Estimated Premium ________________________ Trust Experience Mod. __________________________ Excess Carrier ________________________________ Standard Premium ______________________________ Policy Number ________________________________ Estimated Collectible Premium After Discount _________________________ 7. Applicant will Submit: A. Specific Excess Insurance C. Surety Bond Policy Limit $____________________ Amount Retention $____________________ Bond Number Term B. _______________ to _______________ Aggregate Excess Insurance Policy Limit Term D. Fidelity Bond Amount _______________ to _______________ Bond Number Loss Fund ______% of collectible premium after any discount $____________________ ____________________ Carrier _________________________________ $____________________ Loss Limit ____________________ Carrier _________________________________ $____________________ Loss Fund $____________________ $____________________ Est. Min. Loss Fund $____________________ In consideration of the privilege of being a self-insurer, we hereby agree: a. That we will discharge our liability for compensation to injured employees or their dependents in accordance with the requirements of the Workers’ Compensation Act of the State of Missouri. b. That we will follow the Administrative Rules of the Division and any additional conditions imposed by the Division as part of our approval. c. That we will promptly furnish all reports to the Division of Workers’ Compensation which it may lawfully require under the Workers’ Compensation Act. d. That we will notify the Division of Workers’ Compensation promptly of any unfavorable turn in our financial condition which might reasonably reduce our ability to carry our own risk under the Workers’ Compensation Act. We affirm all information submitted as being true. _____________________________________________ (Group Fund) by _____________________________________________ (Official Title) Date ______________________________ WC-81A-2 AI 2000 (C) American LegalNet, Inc. _________________________________________________________________________________________________ Name of Trust Fund Effective ____________________ to ____________________ Amount of Payroll by Classification for Current Year of Trust Fund Code Classification Payroll Manual Premium ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ ________ __________________________________ _____________________ _________________________ TOTALS _____________________ _________________________ Standard Premium _________________________ Loss History Experience Date Gross Payroll Total Losses _____________________ year _____________________ _________________________ _____________________ year _____________________ _________________________ _____________________ year _____________________ _________________________ _____________________ year _____________________ _________________________ _____________________ year _____________________ _________________________ Losses over $10,000 past 5 years: Date Total Amount _____________________ year _____________________ _____________________ year _____________________ _____________________ year _____________________ _____________________ year _____________________ _____________________ year _____________________ WC-81A-3 AI 2000 (C) American LegalNet, Inc.